Transition Policy

Health Alliance Plan of Michigan provides a transition process that is consistent with 42 CFR §423.120(b)(3) and includes a written description of how enrollees whose current drug therapies may not be included in the HAP formulary may receive a temporary supply of a non-formulary drug, as well as Part D drugs that are on the formulary but require prior authorization or step therapy or are subject to quantity limits under the HAP Senior Plus utilization management rules. A meaningful transition period allows sufficient time for members to work with their health care provider to select an appropriate formulary alternative or to request a formulary exception based on medical necessity.

The Transition Policy applies to the following enrollees:

  • New enrollees into prescription drug plans at the beginning of a contract year
  • The transition of newly eligible Medicare beneficiaries from other coverage at the beginning of a contract year
  • The transition of individuals who switch from one plan to another after the beginning of a contract year
  • Enrollees residing in long-term care (LTC) facilities
  • Current enrollees affected by formulary changes from one contract year to the next

Transition Fills in the outpatient (retail) setting

The outpatient pharmacy setting includes retail, home infusion and safety net and I/T/U pharmacies. A temporary, 30-day supply (unless the prescription is written for less than a 30-day supply) of non-formulary drugs will be provided anytime during the 90-day transition period.

Transition Fills in the Long Term Care (LTC) setting

Multiple fills of a temporary, 31-day supply (unless the prescription is written for less than a 31-day supply) will be provided during the 90-day transition period. HAP Senior Plus honors multiple fills of non-formulary Part D drugs during the entire length of the 90-day transition period, for up to a 98-day supply.

Emergency supplies and level of care changes

An emergency transition supply is defined by CMS as a one-time fill of a nonformulary drug that is necessary with respect to current members in the LTC setting, and will be provided to current long-term care enrollees who enter into a facility from another care setting. HAP Senior Plus have authorized our claims processor to place a manual override at the point of sale to accommodate a one-time (up to 31 days) fill in this scenario.

Transition across contract years

CMS transition guidance requires that current members affected by a negative formulary change across contract years are provided with a transition process that is consistent with the transition process required for new enrollees. Logic is in place at the point of sale to accommodate this by allowing current members to access transition supplies when their claims history from the previous calendar year contains an approved claim for the same drug that the member is attempting to fill through transition.

Transition extension

HAP Senior Plus acknowledges that situations may exist in which the member’s transition period may need to be extended, on a case-by-case basis, such as when the member's exception request or appeal has not been processed by the end of the minimum transition period and until such time as a transition has been made. In these situations, HAP may extend the member’s transition period in order to provide continued coverage of the transition drug.

Cost sharing for transition supplies

For low-income subsidy (LIS) eligible beneficiaries, the cost-sharing amount applied does not exceed the statutory maximum copayment amounts. For non-LIS members filling nonformulary drugs, the cost-sharing amount applied during claims adjudication will be consistent with the plan’s approved cost-sharing tiers for non-formulary drugs. Additionally, for non-LIS members filling formulary drugs with UM requirements, the cost-sharing amount applied during claims adjudication is the cost associated with the plan’s assigned formulary tier.

Protected Class Medications

Per CMS guidance, members who are in transition while taking a drug within a protected drug class must be granted continued coverage of therapy for the duration of treatment, up to the full duration of active enrollment in the plan. Prior authorization and step therapy restrictions, which may apply to new members naïve to therapy, are not applied to those members transitioning to the Medicare Part D plan on agents within these key drug classes.

There are six protected classes of medications:
  • Antidepressant
  • Antipsychotic
  • Anticonvulsant
  • Antineoplastic
  • Antiretroviral
  • Immunosuppressant (for prophylaxis of organ transplant rejection)
Member Notification Transition fill notification occurs in two ways:
  • Point-of-sale notification goes to the pharmacy at time of adjudication with messaging that may be passed to the member regarding the status of the particular nonformulary drug or drug with utilization management. The transition messaging goes to pharmacies in a retail setting (including home infusion, safety net and Indian Tribal Union) as well as pharmacies in an LTC setting.

  • HAP will send written notice via U.S. first-class mail to an enrollee within three business days of adjudication of a temporary fill.
    The notice will include:
    An explanation of the temporary nature of the transition supply the enrollee has received
    Instructions for working with the plan sponsor and the enrollee’s prescriber to identify appropriate therapeutic alternatives that are on the plan’s formulary
    An explanation of the enrollee’s right to request a formulary exception
    A description of the procedures for requesting a formulary exception

Exception Process

Formulary exception request forms will be available to members, their appointed representatives and doctors via mail, fax, e-mail and our website.

Download the 2017 Transition Policy

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